Optimal combination secondary prevention drug treatment and stroke outcomes

Abstract

Objective: To investigate the effect of optimal combination of evidence-based drug therapies including antihypertensive agents, lipid modifiers, and antithrombotic agents on risk of recurrent vascular events after stroke.

Methods: We analyzed the database of a multicenter trial involving 3,680 recent noncardioembolic stroke patients aged 35 years or older and followed for 2 years. Patients were categorized by appropriateness level 0 to III depending on the number of drugs prescribed divided by the number of drugs potentially indicated for each patient (0 = none of the indicated medications prescribed and III = all indicated medications prescribed). Independent associations of medication appropriateness level with recurrent stroke (primary outcome), stroke/coronary heart disease/vascular death as major vascular events (secondary outcome), and death (tertiary outcome) were assessed.

Results: The unadjusted rate of stroke declined with increasing medication appropriateness level (15.9% for level 0, 10.3% for level I, 8.6% for level II, and 7.3% for level III). Compared with level 0: the adjusted hazard ratio of stroke for level I was 0.51 (95% confidence interval, 0.21-1.25), level II 0.50 (0.23-1.09), and level III 0.39 (0.18-0.84); of stroke/coronary heart disease/vascular death for level I 0.60 (0.32-1.14), level II 0.45 (0.25-0.80), and level III 0.39 (0.22-0.69); and of death for level I 0.89 (0.30-2.64), level II 0.71 (0.26-1.93), and level III 0.35 (0.13-0.96).

Conclusions: Optimal combination of secondary prevention medication classes after a recent noncardioembolic stroke is associated with a significantly lower risk of stroke, major vascular events, and death.

Figure 1. Adjusted effect of drug treatment on stroke (A) and major vascular events (B) after noncardioembolic stroke

Secondary prevention medication classes were categorized by appropriateness level strata (0 to III) depending on the number of the drugs prescribed divided by the number of the drugs potentially indicated for each patient (0 = none of the indicated medications prescribed, and III = all indicated medications prescribed). CHD = coronary heart disease; CI = confidence interval; HR = hazard ratio.

Figure 2. Adjusted effect of drug treatment on all-cause death after noncardioembolic stroke

Secondary prevention medication classes were categorized by appropriateness level strata (0 to III) depending on the number of drugs prescribed divided by the number of drugs potentially indicated for each patient. CI = confidence interval; HR = hazard ratio.